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Get Direct Deposit Request Form

9 Lincoln, NE 68521 Toll Free: (888) 728-5611 Fax: (402) 479-0102 Web Site: www.PacificLife.com Use this form to establish or change an existing direct deposit program. 1 GENERAL INFORMATION Claimant/Payee Name (First, Middle, Last) Telephone Number Annuity Contract Number ( ) City, State, ZIP Address 2 BANK/DEPOSITORY INFORMATION I, (print name) am/will be receiving payments. As a payee I request that the payment be electronically deposited.

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